1. Administration Process
2. Provision of ancillary services
3. Suitability of scheme for those aged under 65
1. Administration Process
It is vital that there is consistency in the assessment of older people and the processing of applications. The Ombudsman is also concerned to ensure that there are no undue delays in processing applications under the Scheme. This has taken on an added importance since the change in date of provision of financial assistance from the date of application to the date of approval under the Scheme. There is a danger that pressure will increase on acute hospitals as patients wait for approval before entering a nursing home.
It is also uncertain whether clear and accessible information is being provided to residents and/or families regarding their options under the NHSS. At the commencement of the Scheme, the Department and the then Minister emphasised the concept of a “minimum retained income threshold” – where the spouse or partner remaining at home is left with 50% of the couple’s income or the maximum rate of the State Pension (Non-Contributory) whichever is the greater. However, we have confirmed with the Department that the “minimum retained income threshold”, applies only if the applicant has applied for ancillary state support. Many complainants to the Ombudsman do not seem to be aware of this.
2. Provision of ancillary services
It is important that there is, at the very least, clarity on the issue of the provision of ancillary services and, in particular, as to what is and is not covered under the NHSS. There is a perception that “add-on” charges (and therefore the shortfall to be paid by residents and their families) are increasing to cover the costs of therapies and other services provided to residents, irrespective of whether they hold a Medical Card or not. The Ombudsman has received a significant number of complaints regarding the refusal of services, such as therapies, to medical card holders based purely on the applicant’s residence in a private nursing home. While some of these complaints were ultimately resolved, it is not clear if there is equitable and needs based access to such services across the country. It is hoped that the HSE Working Group on the Provision of Ancillary Services has addressed this and will publish its report shortly on this matter.
In this regard, the definition of long term residential care services as constituting “maintenance, health or personal care services appropriate to the level of care needs of the person” is inadequate. There is no interpretation of what this actually means. While the Department is of the view that it is not possible to be prescriptive in legislation, as each resident may have different care needs, in practice it is being interpreted quite narrowly to include bed and board, basic aids and appliances and nursing care only. The reality is that many of those in need of long-term care require more than this. If the Department is considering further expanding the Scheme into the mental health and disability sectors (where there is often a great need for therapies and other supports) and if the same interpretation is applied, it is anticipated that the additional costs for those availing of such services would increase even further.
3. Suitability of scheme for those aged under 65
The Ombudsman has concerns about the suitability of the Scheme for those aged under 65 or “young chronic sick” as they are sometimes categorised. It must be remembered that for those aged under 65 and their families, there may be costs associated with ordinary daily living such as travel costs to work, that those over 65 do not, as a whole, have to contend with. In addition, many of those aged over 65 have the benefit of the Household Benefits Package awarded by the Department of Social Protection and other supports which are often not available to those aged under 65 who instead have to pay household bills without any subsidy. While the Ombudsman welcomes the regulation that allowed mortgage payments to be deducted in the means assessment, we are concerned that, aside from a provision relating to an asset transferred prior to October 2008, there remains no discretion to allow for an applicant’s (and their families’) financial and other circumstances in life to be taken into account.
It is also a reality that many of the younger applicants, some with acquired brain injuries or neurodegenerative disorders, require much more than bed and board, basic appliances and nursing care. Like some older people, they require rehabilitation services, sometimes at intensive levels. The NHSS was designed for elderly residents with similar needs that can mostly be provided by nursing and care staff. The NHSS envisaged that other services would be accessed via primary or community care services, but this is not what has routinely transpired. The NHSS model does not fit the needs of all persons requiring long-stay care. In many respects, the Scheme is not appropriate for the needs and requirements of high-dependency residents with significant medical, nursing and therapy requirements. Instead, many of the applicants and their families are reliant on the discretion of the local HSE Disability services or other services on the ground to provide “top-up” funding to meet the costs of nursing home care. This is an uncertain and unsustainable situation.